Clinical Presentation and Diagnostic Evaluation of Acute Pericarditis

8/7/2015
Clinicalpresentationanddiagnosticevaluationofacutepericarditis
OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate
Author
MassimoImazio,MD,
FESC
SectionEditor
MartinMLeWinter,MD
DeputyEditor
BrianCDowney,MD,
FACC
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jun2015.|Thistopiclastupdated:Oct31,2014.
INTRODUCTIONThepericardiumisafibroelasticsacmadeupofvisceralandparietallayersseparatedby
a(potential)space,thepericardialcavity.Inhealthyindividuals,thepericardialcavitycontains15to50mLof
anultrafiltrateofplasma.Pericardialdiseasesarerelativelycommoninclinicalpracticeandmayhavedifferent
presentationseitherasisolateddiseaseorasamanifestationofasystemicdisorder.Althoughtheetiologyis
variedandcomplex,thepericardiumhasarelativelynonspecificresponsetothesedifferentcauseswith
inflammationofthepericardiallayersandpossibleincreasedproductionofpericardialfluid.Chronic
inflammationwithfibrosisandcalcificationcanleadtoarigid,usuallythickenedandcalcifiedpericardium,with
possibleprogressiontopericardialconstriction.
Diseasesofthepericardiumpresentclinicallyinoneofseveralways[1]:
Acuteandrecurrentpericarditis
Pericardialeffusionwithoutmajorhemodynamiccompromise
Cardiactamponade
Constrictivepericarditis
Effusiveconstrictivepericarditis
Acutepericarditisreferstoinflammationofthepericardialsac.Thetermmyopericarditis,orperimyocarditis,is
usedforcasesofacutepericarditisthatalsodemonstratemyocardialinflammation.Theclinicalpresentation
anddiagnosticevaluationforacutepericarditiswillbereviewedhere.Theetiologyofpericarditis,treatmentand
prognosisofacutepericarditis,andotherpericardialdiseaseprocessesarediscussedseparately.(See
"Etiologyofpericardialdisease"and"Treatmentofacutepericarditis"and"Recurrentpericarditis"and
"Myopericarditis"and"Cardiactamponade"and"Constrictivepericarditis"and"Diagnosisandtreatmentof
pericardialeffusion".)
EPIDEMIOLOGYAcutepericarditisisthemostcommondisorderinvolvingthepericardium.Epidemiologic
studiesarelacking,andtheexactincidenceandprevalenceofacutepericarditisareunknown.However,acute
pericarditisisrecordedinabout0.1to0.2percentofhospitalizedpatientsand5percentofpatientsadmittedto
theEmergencyDepartmentfornonischemicchestpain[2,3].
InanobservationalstudyfromanurbanareainNorthernItalytheincidenceofacutepericarditiswas27.7
casesper100,000personsperyear[4].
InanobservationalstudyfromFinlandthatincluded670,409cardiovascularadmissionsto29hospitals
acrossthecountryovera9.5yearperiod,thestandardizedincidencerateforpericarditisrequiring
hospitalizationwas3.3casesper100,000personyears[3].
Acutepericarditisisacommondisorderinseveralclinicalsettings,whereitmaybethefirstmanifestationof
anunderlyingsystemicdiseaseormayrepresentanisolatedprocess(table1).Indevelopedcountries,most
casesofacutepericarditisareconsideredofpossibleorconfirmedviralorigin,althoughtheexactetiologyof
mostcasesremainsundeterminedfollowingatraditionaldiagnosticapproach[57].
Priortothewidespreadavailabilityofantiretroviraltherapytotreatinfectionwiththehumanimmunodeficiency
virus(HIV),pericardialdiseasewasthemostfrequentcardiovascularmanifestationoftheacquiredimmune
deficiencysyndrome(AIDS)[8,9].However,indevelopedcountrieswithaccesstoHIVtherapy,patientswith
HIVinfectionwhodevelopacutepericarditishaveanetiologicspectrumverysimilartononHIVinfected
patients.Onthecontrary,HIVinfectionandtuberculosispersistasmajorcausesofacutepericarditisin
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developingcountries.(See"CardiacandvasculardiseaseinHIVinfectedpatients",sectionon'Pericardial
disease'.)
CLINICALFEATURESAcutepericarditiscanpresentinavarietyofways,dependingontheunderlying
etiology.Patientswithaninfectiousetiologymaypresentwithsignsandsymptomsofsystemicinfectionsuch
asfeverandleukocytosis.Viraletiologiesinparticularmaybeprecededbyflulikerespiratoryor
gastrointestinalsymptoms.Patientswithaknownautoimmunedisorderormalignancymaypresentwithsigns
orsymptomsspecifictotheirunderlyingdisorder.
Themajorclinicalmanifestationsofacutepericarditisinclude[5]:
Chestpaintypicallysharpandpleuritic,improvedbysittingupandleaningforward
Pericardialfrictionrubasuperficialscratchyorsqueakingsoundbestheardwiththediaphragmofthe
stethoscopeovertheleftsternalborder
Electrocardiogram(ECG)changesnewwidespreadSTelevationorPRdepression
Pericardialeffusion
ChestpainThevastmajorityofpatientswithacutepericarditispresentwithchestpain(>95%ofcases)
[10].Chestpainislikelytobepresentincasesofacutepericarditiscausedbyinfection,butmaybeminimalor
absentinpatientswithuremicpericarditisorpericarditisassociatedwitharheumatologicdisorder(althoughin
somepatientspleuriticchestpainandpericarditisistheinitialpresentationofsystemiclupuserythematosus).
Chestpainthatresultsfromacutepericarditisistypicallyfairlysuddeninonsetandoccursovertheanterior
chest.Unlikepainfrommyocardialischemia,chestpainduetopericarditisismostoftensharpandpleuriticin
nature,withexacerbationbyinspirationorcoughing.Oneofthemostdistinctivefeaturesisthetendencyfora
decreaseinintensitywhenthepatientsitsupandleansforward[5,11].Thisposition(seated,leaningforward)
tendstoreducepressureontheparietalpericardium,particularlywithinspiration,andmayalsoallowfor
splintingofthediaphragm[12].
However,dull,oppressivepainorradiationofthepaintotheshoulders(particularlythetrapeziusridges)may
occurinsuchcasesitisdifficulttodistinguishpericarditisfromothercausesofchestpain[5,11].Thechest
painofpericarditismustalwaysbedistinguishedfromothercommonand/orlifethreateningcausesofchest
painsuchasmyocardialischemia,pulmonaryembolism,aorticdissection,gastroesophagealrefluxdisease,
andmusculoskeletalpain.(See"Differentialdiagnosisofchestpaininadults".)
PericardialfrictionrubThepresenceofapericardialfrictionrubonphysicalexaminationishighlyspecific
foracutepericarditis(movie1).Pericardialfrictionrubs,whichoccurduringthemaximalmovementoftheheart
withinitspericardialsac,aresaidtobegeneratedbyfrictionbetweenthetwoinflamedlayersofthe
pericardium.However,thiscommonlyofferedexplanationforitsmechanismmaybeanoversimplificationas
patientswithapericardialeffusionmayalsohaveanaudiblefrictionrub.
Theclassicfrictionrubconsistsofthreephases,correspondingtomovementoftheheartduringatrialsystole
(whichisnotheardinpatientswithatrialfibrillation),ventricularsystole,andtherapidfillingphaseofearly
ventriculardiastole.However,somerubsarepresentonlyduringone(onecomponent)ortwophases(two
components)ofthecardiaccycle[13].Inareviewofauscultationandphonocardiographyin100patientswitha
pericardialrub,therubwastriphasicin56percentofpatientsinsinusrhythmoverall,biphasicrubswere
presentin33percentandmonophasicrubsin15percent[13].
Pericardialrubshaveasuperficialscratchyorsqueakingqualitythatisbestheardwiththediaphragmofthe
stethoscope.Theymaybelocalizedorwidespread,butareusuallyloudestovertheleftsternalborder[13].The
intensityoftherubfrequentlyincreasesafterapplicationoffirmpressurewiththediaphragm,duringsuspended
respiration,andwiththepatientleaningforwardorrestingonelbowsandknees(picture1).Thislastmaneuver
isdesignedtoincreasecontactbetweenvisceralandparietalpericardium,butisseldomusedinpracticesince
itiscumbersomeforthepatient.
Frictionrubstendtovaryinintensityandcancomeandgooveraperiodofhourstherefore,thesensitivityfor
detectionofarubisvariableanddependsinlargepartonthefrequencyofauscultation[11].Pericardialrubs
maybeeasiertohearinpatientswithoutapericardialeffusion,butthisfindingisnotuniversalandisnotwell
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documented.Inareportof100patientswithacutepericarditis,apericardialrubwaspresentin34of40(85
percent)withoutaneffusion[14].Thisprevalenceisconsiderablyhigherthanthe35percentincidenceof
frictionrubsreportedinanotherseries[10].
Suspensionofrespirationduringauscultationpermitsdistinctionofapericardialfrictionrubfroma
pleuropericardialorpleuralrub.Apleuropericardialrubresultsfromthefrictionbetweentheinflamedpleuraand
theparietalpericardium,whileapleuralrubistheresultoffrictionbetweentheinflamedvisceralandparietal
pleura.Assuch,pleuropericardialandpleuralrubscanbeheardonlyduringtheinspiratoryphaseofrespiration.
(See"Auscultationofheartsounds",sectionon'Pericardialfrictionrubandotheradventitioussounds'.)
ElectrocardiogramChangesintheelectrocardiogram(ECG)inpatientswithacutepericarditissignify
inflammationoftheepicardium,sincetheparietalpericardiumitselfiselectricallyinert.However,some
causesofpericarditisdonotresultinsignificantinflammationoftheepicardiumand,assuch,maynotalterthe
ECG.Anillustrationofthisisuremicpericarditis,inwhichthereisprominentfibrindepositionbutlittleorno
epicardialinflammation.Asaresult,theECGoftenshowsnoneofthechangesassociatedwithpericarditis
[15].(See"Pericarditisinrenalfailure".)
Theelectrocardiogram(ECG)inacutepericarditiscanevolvethroughasmanyasfourstagesofchanges
[5,11].However,pericarditisdoesnotalwaysresultinsignificantECGchanges.Oneseriesof300
consecutivepatientswithacutepericarditisnotedtypicalECGevolutionin60percentofcases[10].
ThetypicalprogressionofECGchangesinpatientswithacutepericarditisisdescribedbelow:
Stage1,seeninthefirsthourstodays,ischaracterizedbydiffuseSTelevation(typicallyconcaveup)
withreciprocalSTdepressioninleadsaVRandV1(waveform1).Thereisalsoanatrialcurrentofinjury,
reflectedbyelevationofthePRsegmentinleadaVRanddepressionofthePRsegmentinotherlimb
leadsandintheleftchestleads,primarilyV5andV6.Thus,thePRandSTsegmentstypicallychangein
oppositedirections.PRsegmentdeviation,whichishighlyspecificthoughlesssensitive,isfrequently
overlooked.
TheTPsegmentisrecommendedasthebaselineforcomparisonwhenmeasuringbothPRandST
segmentchangesinacutepericarditis[16].
Stage2,typicallyseeninthefirstweek,ischaracterizedbynormalizationoftheSTandPRsegments.
Stage3ischaracterizedbythedevelopmentofdiffuseTwaveinversions,generallyaftertheST
segmentshavebecomeisoelectric.However,thisstageisnotseeninsomepatients.
Stage4isrepresentedbynormalizationoftheECGorindefinitepersistenceofTwaveinversions
("chronic"pericarditis).
ThetemporalevolutionofECGchangeswithacutepericarditisishighlyvariablefromonepatienttoanother
[16].TreatmentcanaccelerateoralterECGprogression.ThedurationoftheECGchangesinpericarditisalso
dependsuponitscauseandtheextentoftheassociatedmyocardialdamage[17].
AtypicalECGchangesareseeninupto40percentofpatientswithacutepericarditis[10].Forexample,
localizedSTelevationandTwaveinversionoccurbeforeSTsegmentnormalizationinaminorityofpatients
withacutepericarditiswithoutmyocardialinvolvement.ThesechangescansimulateECGchangesseenin
patientswithanacutecoronarysyndrome.(See'ECGdifferentiationfromacutemyocardialinfarction'below
and"ECGtutorial:Myocardialischemiaandinfarction"and"ECGtutorial:STandTwavechanges".)
Sustainedarrhythmiasareuncommoninacutepericarditis,exceptinthepostthoracotomysetting.Thiswas
illustratedinareviewof100consecutivepatientsinwhichonlysevenarrhythmiaswereidentifiedallwere
atrialandalloccurredinpatientswithunderlyingheartdisease[18].Inaseparatereportcomparingpatients
withmyopericarditisandsimpleacutepericarditis,cardiacarrhythmiaswerealsomorecommonlypresentin
patientswithmyopericarditis(oddsratio17.6,95%confidenceinterval5.7to54.1)[4].Thus,thepresenceof
atrialorventriculararrhythmiasissuggestiveofconcomitantmyocarditisoranunrelatedcardiacdisease.
ECGdifferentiationfromacutemyocardialinfarctionWhilebothacutepericarditisandacute
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myocardialinfarctioncanpresentwithchestpainandelevationsincardiacbiomarkers,theelectrocardiographic
changesinacutepericarditisdifferfromthoseinacuteSTelevationMI(STEMI)inseveralways[19].These
distinctionsassumethatthepericarditisdoesnotoccurduringorsoonafteranacuteMI.(See
"Electrocardiograminthediagnosisofmyocardialischemiaandinfarction"and"Pericardialcomplicationsof
myocardialinfarction"and"ECGtutorial:STandTwavechanges"and"ECGtutorial:Myocardialischemiaand
infarction".)
MorphologyTheSTsegmentelevationinacutepericarditisbeginsattheJpoint,whichrepresentsthe
junctionbetweentheendoftheQRScomplex(terminationofdepolarization)andthebeginningoftheST
segment(onsetofventricularrepolarization).TheSTsegmentelevationrarelyexceeds5mm,and
usuallyretainsitsnormalconcavity(waveform1).Insomecasesofacutepericarditis,theSTsegment
risesobliquelyinastraightline.AlthoughsimilarpatternscanoccurwithSTEMI,thetypicalfindingina
STEMIpatientisconvex(domeshaped)STelevation(apatternnotcharacteristicofacutepericarditis)
thatmaybemorethan5mminheight(waveform2).Thebasisforthesemorphologicdifferencesisnot
known,butisprobablyrelatedtothegreaterinjurycurrentassociatedwithinfarction.
DistributionSTsegmentelevationsinSTEMIarecharacteristicallylimitedtoanatomicalgroupingsof
leadsthatcorrespondtothelocalizedvascularareaoftheinfarct(anteroseptalandanteriorleadsV1to
V4lateralleadsI,aVL,V5,V6inferiorleadsII,III,aVF)(waveform2).Thepericardiumenvelopsthe
heart,thereforetheSTchangesaremoregeneralizedandtypicallyarepresentinmostleads(waveform
1).Inpericarditis,STsegmentelevationintheprecordialleadsismostcommonlyseeninV5andV6,and
indecreasingfrequencyfromV4toV1,whileinthelimbleads,itisoftenmoreevidentinleadsIandII
thaninleadsIII,aVF,andaVL[17].
ReciprocalchangesAcuteSTEMIisoftenassociatedwithreciprocalSTsegmentchanges,whichare
notseenwithpericarditisexceptinleadsaVRandV1.
ConcurrentSTandTwavechangesSTsegmentelevationandTwaveinversionsdonotgenerally
occursimultaneouslyinpericarditis,whiletheycommonlycoexistinacuteSTEMI(waveform2).
Furthermore,theevolutionofrepolarizationabnormalitiesoftentakesplacemoreslowlyandmore
asynchronouslyamongaffectedleadsinpericarditisthaninSTEMI.
HyperacuteTwavesPeakedTwaves(>10mmhighinprecordialleads,>5mmhighinlimbleads),also
referredtoashyperacuteTwaves,canbeseeninSTEMIbutarenottypicalofpericarditis(waveform
3AB).Rarely,fusionoftheSTsegmentandTwaveintoasinglemonophasicwaveinpericarditiscan
mimictheappearanceofhyperacuteTwaves.
QwavesPathologicQwaves,whichmayoccurwithextensiveinjuryinSTEMI,aregenerallynotseen
inpericarditis.TheabnormalQwavesinMIreflectthelossofpositivedepolarizationvoltagesbecauseof
transmuralmyocardialnecrosis.Pericarditis,ontheotherhand,generallycausesonlysuperficial
inflammation.AbnormalQwavesarenotseenunlessthereisconcomitantmyocarditisorpreexisting
cardiomyopathyormyocardialinfarction.
PRsegmentPRelevationinaVRwithPRdepressioninotherleadsduetoaconcomitantatrialcurrent
ofinjuryisfrequentlyseeninacutepericarditisbutrarelyseeninacuteSTEMI.
QTprolongationProlongationoftheQTintervalwithregionalTwaveinversion(intheabsenceofdrug
effectsorrelevantmetabolicdisorders)favorsthediagnosisofmyocardialischemia(ormyopericarditis)
overpericarditisalone.
ECGdifferentiationfromearlyrepolarizationTheearlyrepolarizationvariantseenonanECGmaybe
presentinasmanyas30percentofyoungadultsandisoftenconfusedwithacutepericarditis[20].Early
repolarizationischaracterizedbySTelevationoftheJpoint,whichrepresentsthejunctionbetweentheendof
theQRScomplex(terminationofdepolarization)andthebeginningoftheSTsegment(onsetofventricular
repolarization).Asaresult,thereiselevationoftheSTsegmentitself,whichmaintainsitsnormalconfiguration
(waveform4).Inearlyrepolarization,STelevationismostoftenpresentintheanteriorandlateralchestleads
(V3V6),althoughotherleadscanbeinvolved.(See"ECGtutorial:Miscellaneousdiagnoses",sectionon'Early
repolarization'.)
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Thefollowingelectrocardiographicfeaturescanbehelpfulindistinguishingacutepericarditisfromearly
repolarization:
STelevationsoccurinboththelimbandprecordialleadsinmostcasesofacutepericarditis(47of48in
onestudy),whereasaboutonehalfofsubjectswithearlyrepolarizationhavenoSTdeviationsinthelimb
leads[21].
PRdeviationandevolutionoftheSTandTchangesstronglyfavorpericarditis,asneitherisseeninearly
repolarization.
IftheratioofSTelevationtoTwaveamplitudeinleadV6exceeds0.24,acutepericarditisispresent
(positiveandnegativepredictivevaluesareboth100percent)[22].
Laboratoryandimagingfindings
EchocardiogramEchocardiographyisoftennormalinpatientswiththeclinicalsyndromeofacute
pericarditisunlessthereisanassociatedpericardialeffusion.Whilethefindingofapericardialeffusionina
patientwithknownorsuspectedpericarditissupportsthediagnosis,theabsenceofapericardialeffusionor
otherechocardiographicabnormalitiesdoesnotexcludeit.Inoneseriesof300consecutivepatientswithacute
pericarditis,pericardialeffusionwaspresentin180patients(60percent).Inmostcasestheeffusionwassmall
ormoderateinsize(79and10percent,respectively)withouthemodynamicconsequences.Cardiactamponade
waspresentinonly5percentofpatients[10].(See"Echocardiographicevaluationofthepericardium"and
"Diagnosisandtreatmentofpericardialeffusion".)
ChestxrayChestradiographyistypicallynormalinpatientswithacutepericarditis.Althoughpatients
withasubstantialpericardialeffusionmayexhibitanenlargedcardiacsilhouettewithclearlungfields(image
1),thisfindingisuncommoninacutepericarditissinceatleast200mLofpericardialfluidmustaccumulate
beforethecardiacsilhouetteenlarges[2,5].However,acutepericarditisshouldbeconsideredintheevaluation
ofapatientwithnewandotherwiseunexplainedcardiomegaly.
CardiacbiomarkersAcutepericarditismaybeassociatedwithincreasesinserumbiomarkersof
myocardialinjurysuchascardiactroponinIorT.Inoneseriesof118consecutivecaseswithidiopathicacute
pericarditisanelevatedlevelofcardiactroponinIwasdetectedin38patients(32percent)[23].Suchpatients
shouldbeconsideredtohavemyopericarditis.(See'Myopericarditis'belowand"Myopericarditis",sectionon
'Laboratorystudies'.)
SignsofinflammationSincepericarditisisaninflammatorydisease,laboratorysignsofinflammation
arecommoninpatientswithacutepericarditis.Theseincludeelevationsinthewhitebloodcellcount,
erythrocytesedimentationrate,andserumCreactiveproteinconcentration.Whileelevationinthesemarkers
supportsthediagnosis,theyareneithersensitivenorspecificforacutepericarditis.Additionally,inthe
hyperacutephaseofpericarditis,thesemarkersmayremainnormalandincreasedlevelsmaybefoundonlyon
followup.
DIAGNOSISThediagnosisofacutepericarditisisusuallysuspectedbasedonahistoryofcharacteristic
pleuriticchestpain,andconfirmedifapericardialfrictionrubispresent.Pericarditisshouldalsobesuspected
inapatientwithpersistentfeverandpericardialeffusionornewunexplainedcardiomegaly.Additionaltesting,
whichtypicallyincludesbloodwork,chestradiography,electrocardiography,andechocardiography,can
supportthediagnosisbutisfrequentlynormalorunrevealing.Theelectrocardiogramisusuallythemosthelpful
testintheevaluationofpatientswithsuspectedacutepericarditis.Echocardiographyisoftennormal,butcan
beanessentialpartoftheevaluationifthereisevidenceofanassociatedpericardialeffusionand/orsignsof
cardiactamponade.
EvaluationForapatientwhopresentswithsuspectedacutepericarditis,itisourpracticetoperformthe
followingstudies:
InitialhistoryandphysicalexaminationThisevaluationshouldconsiderdisordersthatareknownto
involvethepericardium,suchaspriormalignancy,autoimmunedisorders,uremia,recentmyocardial
infarction,andpriorcardiacsurgery.Theexaminationshouldpayparticularattentiontoauscultationfora
pericardialfrictionrubandthesignsassociatedwithtamponade.(See"Etiologyofpericardialdisease"
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and"Pericardialdiseaseassociatedwithmalignancy"and"Noncoronarycardiacmanifestationsof
systemiclupuserythematosusinadults",sectionon'Pericardialdisease'and"Pericarditisinrenalfailure"
and"Pericardialcomplicationsofmyocardialinfarction"and"Cardiactamponade".)
Initialtestingshouldinclude:
Anelectrocardiograminallcases.(See'Electrocardiogram'above.)
Chestradiographyinallcases.(See'Chestxray'above.)
Completebloodcount,troponinlevel,erythrocytesedimentationrate,andserumCreactiveprotein
level.(See'Cardiacbiomarkers'above.)
Bloodculturesiffeverhigherthan38C(100.4F)orsignsofsepsis.
Echocardiographyshouldbeperformedinallcases,withurgentechocardiographyifcardiac
tamponadeissuspected.Evenasmalleffusioncanbehelpfulinconfirmingthediagnosisof
pericarditis,althoughtheabsenceofaneffusiondoesnotexcludethediagnosis[24].Inaddition,
echocardiographycanbeparticularlyhelpfulifpurulentpericarditisissuspected,ifthereisconcern
aboutmyocarditis,orifthereisradiographicevidenceofcardiomegaly,particularlyifthisisanew
finding.(See'Echocardiogram'aboveand"Echocardiographicevaluationofthepericardium".)
The2003AmericanCollegeofCardiology/AmericanHeartAssociation/AmericanSocietyof
Echocardiography(ACC/AHA/ASE)guidelinesfortheclinicalapplicationofechocardiographystated
thatevidenceand/orgeneralagreementsupportedtheuseofechocardiographyfortheevaluationof
allpatientswithsuspectedpericardialdisease[25].Similarly,a2013expertconsensusstatement
fromtheASErecommendsechocardiographyforallpatientswithacutepericarditis[24].
Additionaltestingmayinclude:
Tuberculinskintestoraninterferongammareleaseassay(eg,QuantiFERONTBassay)ifnot
recentlyperformed.Theinterferongammareleaseassayismosthelpfulinimmunocompromisedor
HIVpositivepatientsandinregionswheretuberculosisisendemic.(See"Diagnosisofpulmonary
tuberculosisinHIVnegativepatients"and"Tuberculouspericarditis".)
Antinuclearantibody(ANA)titerinselectedcases(eg,youngwomen,especiallythoseinwhomthe
historysuggestsarheumatologicdisorder).Rarely,acutepericarditisistheinitialpresentationof
systemiclupuserythematosus(SLE).ItisimportanttorecognizethatapositiveANAisanon
specifictest.Arheumatologyconsultshouldbesoughtinpatientswithpericarditisinwhoma
diagnosisofSLEisbeingentertained.
HIVserology(see"CardiacandvasculardiseaseinHIVinfectedpatients",sectionon'Pericardial
disease')
Computedtomography(CT)maybeusefultoconfirmthediagnosisandespeciallyevaluate
concomitantpleuropulmonarydiseasesandlymphadenopathies,thussuggestingapossibleetiology
ofpericarditis(ie,TB,lungcancer)[24].Noncalcifiedpericardialthickeningwithpericardialeffusion
issuggestiveofacutepericarditis.Moreover,withtheadministrationofiodinatedcontrastmedia,
enhancementofthethickenedvisceralandparietalsurfacesofthepericardialsacconfirmsthe
presenceofactiveinflammation.Computedtomographicattenuationvaluescanhelpinthe
differentiationofexudativefluid(20to60Hounsfieldunits),asfoundwithpurulentpericarditis,and
simpletransudativefluid(<10Hounsfieldunits).
Cardiacmagneticresonanceimagingmaybeperformediftheechocardiogramisunrevealingbutthe
diagnosisofacutepericarditisissuspected,especiallyinpatientswithongoingfever,poorresponse
totreatment,orsuspicionofhemodynamiccompromise[24].
Multimodalityimagingisanintegralpartofmodernmanagementforpericarditisandpericardialdiseases.
Amongmultimodalityimagingtests,echocardiographyismostoftenthefirstlinetest,followedbyCMR
and/orCT[23].
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Wedonotroutinelyobtainviralstudies,sincetheyieldislowandmanagementisnotaltered[26].
Pericardiocentesisshouldbeperformedfortherapeuticpurposesinpatientswithcardiactamponade.(See
'Pericardiocentesis'belowand"Treatmentofacutepericarditis",sectionon'Interventionaltherapeutic
techniques'.)
Pericardiocentesisshouldbeconsideredfordiagnosticpurposesinpatientssuspectedofhavinga
malignantorbacterialetiology,orinpatientswithaneffusionrefractorytomedicaltherapy.(See
'Pericardiocentesis'below.)
ClinicaldiagnosticcriteriaAcutepericarditisreferstoinflammationofthepericardialsac.Theterm
myopericarditis,orperimyocarditis,isusedforcasesofacutepericarditisthatalsodemonstratefeatures
consistentwithmyocardialinflammation.
Becausethesamevirusesthatareresponsibleforacutepericarditiscanalsocausemyocarditis,itisnot
uncommontofindsomedegreeofmyocardialinvolvementinpatientswithacutepericarditis.Theterms
"myopericarditis"and"perimyocarditis"aresometimesusedinterchangeablyortheycanbeusedtoindicate
thedominantsiteofinvolvement.Casesthatinvolvethemyocardiuminwhichpericarditisispredominantare
reportedasmyopericarditisalternatively,thetermperimyocarditisissometimesusedwhenmyocardial
involvementismostprominent.However,inclinicalpractice,myopericarditisismorecommonandthistermis
oftenusedinbothsenses.(See"Myopericarditis".)
AcutepericarditisAcutepericarditisisdiagnosedbythepresenceofatleasttwoofthefollowing
criteria(table2)[5,11,14,26,27]:
Typicalchestpain(sharpandpleuritic,improvedbysittingupandleaningforward)
Pericardialfrictionrub(asuperficialscratchyorsqueakingsoundbestheardwiththediaphragmofthe
stethoscopeovertheleftsternalborder)(movie1)
Suggestivechangesontheelectrocardiogram(typicallywidespreadSTsegmentelevation)(waveform1)
Neworworseningpericardialeffusion
Whileechocardiographyisoftennormal,andtheabsenceofapericardialeffusiondoesnotexcludepericarditis,
theechocardiogramremainsanessentialpartoftheevaluationifthereisevidenceofanassociatedpericardial
effusionand/orsignsofcardiactamponade.
MyopericarditisWhenacutepericarditisispresent,myopericarditiscanbediagnosedbythedetection
ofoneorbothofthefollowingintheabsenceofevidenceofanothercause[2831]:
Elevationinserumcardiacbiomarkers,suchascardiactroponinIorT
Neworpresumednewfocalorgloballeftventricularsystolicdysfunctiononimagingstudies
Amorecompletediscussionofthediagnosisofmyopericarditisispresentedseparately.(See
"Myopericarditis",sectionon'Diagnosis'.)
IDENTIFYINGTHEETIOLOGYTheyieldofthestandarddiagnosticevaluationtodeterminetheetiologyof
acutepericarditisisrelativelylow.Thiswasillustratedinthreeseriesthatincludedatotalof784unselected
patientswhounderwentanextensiveevaluation[14,26,32].Aspecificdiagnosiswasestablishedinonly130
patients(17percent)(table3).Themostcommonlyconfirmeddiagnoseswere:
Neoplasia5percent
Tuberculosis4percent
Autoimmuneetiologies5percent
Purulentpericarditis1percent
InWesterncountries,unlessthereisanapparentmedicalorsurgicalconditionknowntobeassociatedwith
pericarditis,mostcasesofacutepericarditisinimmunocompetentpatientsareduetoviralinfectionorare
idiopathic(table1andtable3)[6,10,27,3235].Acuteviraloridiopathicpericarditistypicallyfollowsabriefand
benigncourseafterempirictreatmentwithantiinflammatorydrugs.(See"Treatmentofacutepericarditis".)
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Becauseoftherelativelybenigncourseassociatedwiththecommoncausesofpericarditis,itisnotnecessary
tosearchfortheetiologyinallpatientswithacutepericarditis.Initialeffortsshouldfocusuponexcludinga
significanteffusionortamponadeandtheidentificationofpatientsinwhomamorecomprehensiveevaluation
shouldbeperformedtoexcludecausesthatrequirespecifictherapy(eg,malignancy,tuberculosisorpurulent
pericarditis)(table1)[10].Inaddition,amongpatientsathighriskofcoronarydisease,myocardialischemia
mustberuledoutbyappropriatestudies.
IndicationsforpericardiocentesisandpericardialbiopsyStudiesinpatientswithacutepericarditishave
reportedalowyieldfordiagnosticpericardiocentesisandpericardialbiopsyhowever,someauthorshave
advocatedforamoreextensiveuseofthesetechniquesfordiagnosticpurposes.Themajorityofpatientswith
uncomplicatedacutepericarditisdonotrequireinvasivepericardialprocedures.However,somehighrisk
patientsmayrequirepericardiocentesisforboththerapeuticanddiagnosticpurposes(table4).Inaddition,while
pericardialbiopsyisnotrequiredtomakethediagnosisofacutepericarditis,itmayrarelybenecessaryinan
attempttodiagnoseaspecificetiology.(See"Treatmentofacutepericarditis",sectionon'Interventional
therapeutictechniques'.)
PericardiocentesisInpatientswithapericardialeffusion,pericardiocentesisorsurgicaldrainagecan
servebothdiagnosticandtherapeuticpurposes.Amongpatientswithacutepericarditis,decisionsregarding
drainageofthepericardialspacearebaseduponthepresenceofanassociatedeffusion,itsechocardiographic
characteristics(eg,sizeandcomposition),andclinicalsignificance(eg,causinghemodynamiccompromise).
Patientswithsymptomaticeffusionsandevidenceofcardiactamponadeshouldundergoprompt
pericardialdrainage.(See"Cardiactamponade".)
Whenasignificantpericardialeffusionispresent,adiagnosticpericardiocentesisisindicatedifaspecific
etiologyishighlysuspected,anddiagnosiscannotbereachedbyothermeans.Theinvestigationis
especiallyindicatedwhenaneoplasticorbacterialetiologyissuspectedbecauseadefinitediagnosiscan
onlybemadebyidentificationoftheetiologicagentinthepericardialfluid.Fluidsamplesshouldbesent
forcytology,tumormarkers,gramstain,bacterialcultures,and,iftuberculosisissuspected,polymerase
chainreactiontestingfortuberculosis.(See"Diagnosisandtreatmentofpericardialeffusion"and
"Pericardialdiseaseassociatedwithmalignancy".)
Pericardiocentesismaybeconsideredalsoforlargeeffusionsrefractorytomedicaltreatment[36].
Effusionsthataresmalltomoderateinsizeanddonotcausehemodynamiccompromise(ie,cardiac
tamponade)generallydonotrequiredrainage,unlessasampleoftheeffusionisnecessaryfordiagnostic
purposes.Moreover,pericardiocentesisperformedpercutaneouslyhasasignificantlyhighercomplication
rateiftheeffusionisnotlarge.
Adetaileddiscussionregardingtheperformanceofpericardiocentesisandthetreatmentofpericardialeffusions
ispresentedseparately.(See"Diagnosisandtreatmentofpericardialeffusion".)
PericardialbiopsyPericardialbiopsyisgenerallyperformedasapartofatherapeuticprocedure
(surgicaldrainage)inpatientswithrecurrentpericardialeffusionsandcardiactamponadeafterprior
pericardiocentesis(therapeuticbiopsy),andasadiagnosticprocedureinpatientswithanillnesslastingmore
thanthreeweeksdespitetreatmentwithoutadefinitediagnosis.Technicaladvancesininstrumentationwith
introductionofpericardioscopy,andincontemporaryvirologyandmolecularbiologyhaveimprovedthe
diagnosticvalueofepicardial/pericardialbiopsy.Thediagnosticyieldofpericardialbiopsyistypicallyhigherin
patientswithpericardialeffusionwithorwithoutpericarditisthaninthosewhopresentwithapparentacute
pericarditiswithouteffusion.Polymerasechainreactiontechniquesmayrepresentausefuladjunctto
conventionallaboratorystudiesintheinvestigationofpericardialsamples,allowingtherapididentificationof
microorganismsotherwisenoteasilyfound[36,37].Tissuesamplesshouldbesentforcytology,tumor
markers,gramstain,bacterialcultures,and,iftuberculosisissuspected,polymerasechainreactiontesting.
(See"Diagnosisandtreatmentofpericardialeffusion",sectionon'Pericardialfluidanalysisandbiopsy'.)
DETERMINATIONOFRISKANDNEEDFORHOSPITALIZATIONManycliniciansadmitallnewcases
ofacutepericarditistothehospital,butthismaynotbenecessary.Apatientwithuncomplicatedacute
pericarditiscanundergoinitialevaluationinasamedayhospitalfacilityorclinic,althoughoutpatientfollowup
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isrequired[6,10,32,35].Ontheotherhand,patientswithhighriskfeaturesareatincreasedriskofshortterm
complicationsandhaveahigherlikelihoodofaspecificdisease[10,32].Hospitaladmissionisindicatedfor
highriskpatientsinordertoinitiateappropriatetherapyandathoroughetiologicevaluation.
Featuresofacutepericarditisassociatedwithahigherriskinclude[10,32]:
Fever(>38C[100.4F])andleukocytosis
Evidencesuggestingcardiactamponade
Alargepericardialeffusion(ie,anechofreespaceofmorethan20mm)
Immunosuppressedstate
AhistoryoftherapywithvitaminKantagonists(eg,warfarin)
Acutetrauma
FailuretorespondwithinsevendaystoNSAIDtherapy
Elevatedcardiactroponin,whichsuggestsmyopericarditis
Inonereportof300consecutivepatientswithacutepericarditis,15percentweredeemedhighriskat
presentationandwerehospitalized[10].Intheremaining85percentofpatientswhowerelowrisk,outpatient
aspirintherapywaseffectivein87percent,andnoneofthesepatientshadaseriouscomplication(eg,cardiac
tamponade)atameanfollowupof38months.
Althoughchronicuseofglucocorticoidsshouldnotbeconsideredasariskfactorinageneralpopulationof
patientswithacutepericarditis,theywereassociatedwithanincreasedrateofcomplicationsinidiopathicor
viralpericarditis[32].Glucocorticoidtherapygivenintheindexattackmayincreasethechanceofrecurrence,
probablybecauseofitsdeleteriouseffectonviralreplicationandclearance.(See"Recurrentpericarditis",
sectionon'Predictorsofrecurrence'.)
Gendermayalsopredictthelikelihoodofcomplications.Inaseriesof453consecutivecasesofacute
pericarditis,womenwereatincreasedriskofcomplications(hazardration1.65,95%CI1.08to2.52)[32].A
possibleexplanationofthisfindingisthehigherfrequencyofautoimmuneetiologies(aboveallconnective
tissuediseases)inwomen.
PROGNOSISPatientswithacuteidiopathicorviralpericarditishaveagoodlongtermprognosis.Cardiac
tamponaderarelyoccursinpatientswithacuteidiopathicpericarditisandismorecommoninpatientswitha
specificunderlyingetiologysuchasmalignancy,tuberculosis,orpurulentpericarditis.Constrictivepericarditis
mayoccurinabout1percentofpatientswithacuteidiopathicpericarditis,andisalsomorecommoninpatients
withaspecificetiology.(See"Constrictivepericarditis".)
Approximately15to30percentofpatientswithidiopathicacutepericarditiswhoarenottreatedwithcolchicine
developeitherrecurrentorincessantdisease.Immunemechanismsappeartobeofprimaryimportanceinthe
majorityofcases,andtheterm"chronicautoreactive"pericarditishasbeenused.Riskfactorsforrecurrent
pericarditisincludelackofresponsetononsteroidalantiinflammatorydrugs,theneedforcorticosteroidtherapy,
andinappropriatepericardiotomyorcreationofapericardialwindow.Thepathogenesis,course,andtreatment
ofrecurrentpericarditisarediscussedseparately.(See"Recurrentpericarditis".)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"
and"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6th
gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoread
materials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.
Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowantindepth
informationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
"patientinfo"andthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Pericarditisinadults(TheBasics)")
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BeyondtheBasicstopic(see"Patientinformation:Pericarditis(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Acutepericarditis(inflammationofthepericardialsac)isthemostcommondisorderofthepericardium
andisseeninabout0.1percentofhospitalizedpatientsand5percentofpatientsadmittedtothe
EmergencyDepartmentfornonischemicchestpain.(See'Epidemiology'above.)
Idiopathiccases,mostofwhichareprobablyviralinetiology,arethemostcommoncausesofacute
pericarditis.Otheretiologiesofacutepericarditisincludeanybacterialinfections,malignancy,and
autoimmunedisorders(table3).Thedistributionofetiologiesvarieswithgeographyandtypeofclinical
setting(communityhospitalversustertiaryreferralcenter).(See'Epidemiology'above.)
Thediagnosisofacutepericarditisisusuallysuspectedbasedonahistoryofcharacteristicpleuritic
chestpain,especiallywhenapericardialfrictionrubispresent.Pericarditisshouldalsobesuspectedina
patientwithpersistentfeverandpericardialeffusionornewunexplainedcardiomegaly.(See'Clinical
features'above.)
Theevaluationofapatientwithsuspectedacutepericarditisincludesbloodwork(assessingformarkers
ofinflammationormyocardialdamage),chestradiography,electrocardiography,andechocardiography.
Theelectrocardiogram(ECG)isoftenthemosthelpfultestintheevaluationofpatientswithsuspected
acutepericarditis.Echocardiographyisoftennormal,butcanbeanessentialpartoftheevaluationifthere
isevidenceofanassociatedpericardialeffusionand/orsignsofcardiactamponade.(See'Diagnosis'
aboveand'Evaluation'above.)
Acutepericarditisisdiagnosedbythepresenceofatleasttwoofthefollowingcriteria(table2):(See
'Diagnosis'above.)
Typicalchestpain(sharpandpleuritic,improvedbysittingupandleaningforward).(See'Chest
pain'above.)
Pericardialfrictionrub(asuperficialscratchyorsqueakingsoundbestheardwiththediaphragmof
thestethoscopeovertheleftsternalborder)(movie1).(See'Pericardialfrictionrub'above.)
Suggestivechangesontheelectrocardiogram(typicallywidespreadSTsegmentelevation)
(waveform1).(See'Electrocardiogram'above.)
Neworworseningpericardialeffusion.(See'Echocardiogram'above.)
Becauseoftherelativelybenigncourseassociatedwiththecommoncausesofpericarditis,itisnot
necessarytosearchfortheetiologyinallpatients.Initialeffortsshouldfocusuponexcludingasignificant
effusionortamponadeandtheidentificationofpatientsinwhomamorecomprehensiveevaluationshould
beperformedtoexcludecausesthatrequirespecifictherapy(eg,malignancy,tuberculosisorpurulent
pericarditis).(See'Identifyingtheetiology'above.)
Apatientwithuncomplicatedacutepericarditiscanundergoinitialevaluationinasamedayhospital
facilityorclinic,althoughoutpatientfollowupisrequired.Conversely,patientswithhighriskfeatures(ie,
highfever,largepericardialeffusion,cardiactamponade,failuretorespondtoempiricantiinflammatory
therapy)areatincreasedriskofshorttermcomplicationsandhaveahigherlikelihoodofaspecific
disease.Hospitaladmissionisindicatedforhighriskpatientsinordertoinitiateappropriatetherapyand
thoroughetiologicevaluation.(See'Determinationofriskandneedforhospitalization'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1. ImazioM.Contemporarymanagementofpericardialdiseases.CurrOpinCardiol201227:308.
2. SpodickDH.Acutecardiactamponade.NEnglJMed2003349:684.
3. KytV,SipilJ,RautavaP.Clinicalprofileandinfluencesonoutcomesinpatientshospitalizedforacute
http://www.uptodate.com/contents/clinicalpresentationanddiagnosticevaluationofacutepericarditis?topicKey=CARD%2F4940&elapsedTimeMs=7&
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pericarditis.Circulation2014130:1601.
4. ImazioM,CecchiE,DemichelisB,etal.Myopericarditisversusviraloridiopathicacutepericarditis.
Heart200894:498.
5. TroughtonRW,AsherCR,KleinAL.Pericarditis.Lancet2004363:717.
6. LangeRA,HillisLD.Clinicalpractice.Acutepericarditis.NEnglJMed2004351:2195.
7. LittleWC,FreemanGL.Pericardialdisease.Circulation2006113:1622.
8. HeidenreichPA,EisenbergMJ,KeeLL,etal.PericardialeffusioninAIDS.Incidenceandsurvival.
Circulation199592:3229.
9. ChenY,BrennesselD,WaltersJ,etal.Humanimmunodeficiencyvirusassociatedpericardialeffusion:
reportof40casesandreviewoftheliterature.AmHeartJ1999137:516.
10. ImazioM,DemichelisB,ParriniI,etal.Dayhospitaltreatmentofacutepericarditis:amanagement
programforoutpatienttherapy.JAmCollCardiol200443:1042.
11. SpodickDH.Acutepericarditis:currentconceptsandpractice.JAMA2003289:1150.
12. Spodick,DH.Acute,clinicallynoneffusive("dry")pericarditis.In:SpodickDH:ThePericardium:A
ComprehensiveTextbook,MarcelDekker,NewYork1997.p.94113.
13. SpodickDH.Pericardialrub.Prospective,Multipleobserverinvestigationofpericardialfrictionin100
patients.AmJCardiol197535:357.
14. ZayasR,AnguitaM,TorresF,etal.Incidenceofspecificetiologyandroleofmethodsforspecific
etiologicdiagnosisofprimaryacutepericarditis.AmJCardiol199575:378.
15. RutskyEA,RostandSG.Pericarditisinendstagerenaldisease:Clinicalcharacteristicsand
management.SeminDial19892:25.
16. Spodick,DH.ThePericardium:AComprehensiveTextbook,MarcelDekker,NewYork1997.p.4664.
17. ChouTC.Electrocardiographyinclinicalpractice,WBSaundersCompany,Philadelphia1996.
18. SpodickDH.Arrhythmiasduringacutepericarditis.Aprospectivestudyof100consecutivecases.
JAMA1976235:39.
19. ChouTC.ElectrocardiographyinClinicalPractice:AdultsandPediatrics,4thed,WBSaunders,
Philadelphia1996.
20. KlatskyAL,OehmR,CooperRA,etal.Theearlyrepolarizationnormalvariantelectrocardiogram:
correlatesandconsequences.AmJMed2003115:171.
21. SpodickDH.Differentialcharacteristicsoftheelectrocardiograminearlyrepolarizationandacute
pericarditis.NEnglJMed1976295:523.
22. GinztonLE,LaksMM.Thedifferentialdiagnosisofacutepericarditisfromthenormalvariant:new
electrocardiographiccriteria.Circulation198265:1004.
23. ImazioM,DemichelisB,CecchiE,etal.CardiactroponinIinacutepericarditis.JAmCollCardiol2003
42:2144.
24. KleinAL,AbbaraS,AglerDA,etal.AmericanSocietyofEchocardiographyclinicalrecommendationsfor
multimodalitycardiovascularimagingofpatientswithpericardialdisease:endorsedbytheSocietyfor
CardiovascularMagneticResonanceandSocietyofCardiovascularComputedTomography.JAmSoc
Echocardiogr201326:965.
25. CheitlinMD,ArmstrongWF,AurigemmaGP,etal.ACC/AHA/ASE2003guidelinefortheclinical
applicationofechocardiographywww.acc.org/qualityandscience/clinical/statements.htm(Accessedon
August24,2006).
26. PermanyerMiraldaG,SagristSauledaJ,SolerSolerJ.Primaryacutepericardialdisease:aprospective
seriesof231consecutivepatients.AmJCardiol198556:623.
27. ImazioM,BobbioM,CecchiE,etal.Colchicineinadditiontoconventionaltherapyforacutepericarditis:
resultsoftheCOlchicineforacutePEricarditis(COPE)trial.Circulation2005112:2012.
28. ImazioMandTrincheroR.Myopericarditis:Etiology,management,andprognosis.IntJCardiol2008
23:127.
29. HalsellJS,RiddleJR,AtwoodJE,etal.Myopericarditisfollowingsmallpoxvaccinationamongvaccinia
naiveUSmilitarypersonnel.JAMA2003289:3283.
30. CassimatisDC,AtwoodJE,EnglerRM,etal.Smallpoxvaccinationandmyopericarditis:aclinical
review.JAmCollCardiol200443:1503.
31. ImazioM,TrincheroR.Triageandmanagementofacutepericarditis.IntJCardiol2007118:286.
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32. ImazioM,CecchiE,DemichelisB,etal.Indicatorsofpoorprognosisofacutepericarditis.Circulation
2007115:2739.
33. MaischB,RistiAD.Theclassificationofpericardialdiseaseintheageofmodernmedicine.Curr
CardiolRep20024:13.
34. PermanyerMiraldaG.Acutepericardialdisease:approachtotheaetiologicdiagnosis.Heart2004
90:252.
35. ImazioM,TrincheroR.Clinicalmanagementofacutepericardialdisease:areviewofresultsand
outcomes.ItalHeartJ20045:803.
36. ImazioM,SpodickDH,BrucatoA,etal.Controversialissuesinthemanagementofpericardial
diseases.Circulation2010121:916.
37. ImazioM,BrucatoA,DerosaFG,etal.Aetiologicaldiagnosisinacuteandrecurrentpericarditis:when
andhow.JCardiovascMed(Hagerstown)200910:217.
Topic4940Version16.0
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GRAPHICS
Majorcausesofpericardialdisease
Idiopathic
Inmostcaseseries,themajorityofpatientsarenotfoundtohaveanidentifiablecauseof
pericardialdisease.Frequentlysuchcasesarepresumedtohaveaviralorautoimmune
etiology.
Infections
ViralCoxsackievirus,echovirus,adenovirus,EBV,CMV,influenza,varicella,rubella,HIV,
hepatitisB,mumps,parvovirusB19,vaccina(smallpoxvaccination)
BacterialStaphylococcus,Streptococcus,pneumococcus,Haemophilus,Neisseria
(gonorrhoeaeormeningitidis),Chlamydia(psittaciortrachomatis),Legionella,tuberculosis,
Salmonella,Lymedisease
Mycoplasma
FungalHistoplasmosis,aspergillosis,blastomycosis,coccidiodomycosis,actinomycosis,
nocardia,candida
ParasiticEchinococcus,amebiasis,toxoplasmosis
Infectiveendocarditiswithvalveringabscess
Radiation
Neoplasm
MetastaticLungorbreastcancer,Hodgkin'sdisease,leukemia,melanoma
PrimaryRhabdomyosarcoma,teratoma,fibroma,lipoma,leiomyoma,angioma
Paraneoplastic
Cardiac
Earlyinfarctionpericarditis
Latepostcardiacinjurysyndrome(Dressler'ssyndrome),alsoseeninothersettings(eg,
postmyocardialinfarctionandpostcardiacsurgery)
Myocarditis
Dissectingaorticaneurysm
Trauma
Blunt
Penetrating
IatrogenicCatheterandpacemakerperforations,cardiopulmonaryresuscitation,post
thoracicsurgery
Autoimmune
RheumaticdiseasesIncludinglupus,rheumatoidarthritis,vasculitis,scleroderma,mixed
connectivedisease
OtherGranulomatosiswithpolyangiitis(Wegener's),polyarteritisnodosa,sarcoidosis,
inflammatoryboweldisease(Crohn's,ulcerativecolitis),Whipple's,giantcellarteritis,
Behcet'sdisease,rheumaticfever
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Drugs
Procainamide,isoniazid,orhydralazineaspartofdruginducedlupus
OtherCromolynsodium,dantrolene,methysergide,anticoagulants,thrombolytics,
phenytoin,penicillin,phenylbutazone,doxorubicin
Metabolic
HypothyroidismPrimarilypericardialeffusion
Uremia
Ovarianhyperstimulationsyndrome
Adaptedfrom:ShabetaiR.Diseasesofthepericardium.In:Hurst'sTheHeart,8thed,SchlantRC,
AlexanderRW,etal(Eds).
Graphic67851Version6.0
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Cardiacauscultationsupineandleaningforward
Auscultationofthepericardium:Toelicitpericardialrubs,thepatientisinvited
toleanforward(A)orrestonelbowsandknees(B).Bothphysicalmaneuvers
increasethecontactofvisceralandparietalpericardium.
Reproducedfrom:Heart,ImazioM.Pericardialinvolvementinsystemicinflammatory
diseases,97:1882,Copyright2011,withpermissionfromBMJPublishingGroupLtd.
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Electrocardiogram(ECG)inpericarditis
ElectrocardiograminacutepericarditisshowingdiffuseupslopingSTsegment
elevationsseenbesthereinleadsII,III,aVF,andV2toV6.Thereisalsosubtle
PRsegmentdeviation(positiveinaVR,negativeinmostotherleads).STsegment
elevationisduetoaventricularcurrentofinjuryassociatedwithepicardial
inflammationsimilarly,thePRsegmentchangesareduetoanatrialcurrentof
injurywhich,inpericarditis,typicallydisplacesthePRsegmentupwardinleadaVR
anddownwardinmostotherleads.
CourtesyofAryGoldberger,MD.
NormalECG
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Normalelectrocardiogramshowingnormalsinusrhythmatarateof75beats/min,aPR
intervalof0.14sec,aQRSintervalof0.10sec,andaQRSaxisofapproximately75.
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Electrocardiogram(ECG)inanevolvinganterior
myocardialinfarction
ElectrocardiogramshowsfindingstypicalofanevolvingQwaveanteriorMI:loss
ofRwavesinleadsV1toV3,STsegmentelevationsinV2toV4,andTwave
inversionsinleadsI,aVL,andV2toV5.Sinusbradycardia(55beats/min)is
presentduetoconcurrenttherapywithabetablocker.
NormalECG
Normalelectrocardiogramshowingnormalsinusrhythmatarateof75beats/min,aPR
intervalof0.14sec,aQRSintervalof0.10sec,andaQRSaxisofapproximately75.
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Hyperacute(peaked)Twaves
HyperacuteTwavesare>5mminthelimbleads,andusually>10mminthe
precordialleads.Theyhaveapeaked,symmetricmorphology.
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NormalECG
Normalsinusrhythmatarateof71beats/min,aPwaveaxisof45,
andaPRintervalof0.15sec.
CourtesyofMortonArnsdorf,MD.
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Earlyrepolarization12leadECG
EarlyrepolarizationmanifestasinferiorJpointslurringandlateralJpointnotching,
each>1mmintwocontiguousleads.
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Chestxrayofapericardialeffusion
Cardiomegalyduetoamassivepericardialeffusion.Atleast200mL
ofpericardialfluidmustaccumulatebeforethecardiacsilhouette
enlarges.
CourtesyofMassimoImazio,MD,FESC.
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Diagnosticcriteriaforacutepericarditisandmyopericarditisinthe
clinicalsetting
Acutepericarditis(atleast2criteriaof4shouldbepresent)*:
1.Typicalchestpain
2.Pericardialfrictionrub
3.SuggestiveECGchanges(typicallywidespreadSTsegmentelevation)
4.Neworworseningpericardialeffusion
Myopericarditis:
1.Definitediagnosisofacutepericarditis,PLUS
2.Suggestivesymptoms(dyspnea,palpitations,orchestpain)andECGabnormalities
beyondnormalvariants,notdocumentedpreviously(ST/Tabnormalities,supraventricularor
ventriculartachycardiaorfrequentectopy,atrioventricularblock),ORfocalordiffuse
depressedLVfunctionofuncertainagebyanimagingstudy
3.Absenceofevidenceofanyothercause
4.Oneofthefollowingfeatures:evidenceofelevatedcardiacenzymes(creatinekinaseMB
fraction,ortroponinIorT),ORnewonsetoffocalordiffusedepressedLVfunctionbyan
imagingstudy,ORabnormalimagingconsistentwithmyocarditis(MRIwithgadolinium,
gallium67scanning,antimyosinantibodyscanning)
Casedefinitionsformyopericarditisinclude:
Suspectedmyopericarditis:criteria1plus2and3
Probablemyopericarditis:criteria1,2,3,and4
Confirmedmyopericarditis :histopathologicevidenceofmyocarditisbyendomyocardial
biopsyoronautopsy
*Pericardialeffusionconfirmstheclinicaldiagnosisbutitsabsencedoesnotexcludeit.
Inclinicalpracticeaconfirmeddiagnosiswouldrequireanendomyocardialbiopsythatisnot
warrantedinselflimitedcaseswithpredominantpericarditis.
Reproducedwithpermissionfrom:ImazioM,TrincheroR.Triageandmanagementofacute
pericarditis.IntJCardiol2006,doi:10.1016/j.ijcard.2006.07.100.Copyright2006Elsevier.
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Acutepericarditisetiology:Datafrompublishedclinicalstudies
withunselectedpopulations
PermanyerMiraldaG.
etal.
(n=231)
ZayasR.et
al.
(n=100)
ImazioM.et
al.
(n=453)
Years
19771983
19911993
19962004
Location
Spain
Spain
Italy
Idiopathic
199(86.0percent)
78(78.0
percent)
377(83.2
percent)
Specificetiology
32(14.0percent)
22(22.0
percent)
76(16.8percent)
Neoplastic
13(5.6percent)
7(7.0percent)
23(5.1percent)
Tuberculosis
9(3.9percent)
4(4.0percent)
17(3.8percent)
Autoimmune
etiologies
4(1.7percent)
3(3.0percent)
33(7.3percent)
Purulent
2(0.9percent)
1(1.0percent)
3(0.7percent)
Datafrom:PermanyerMiraldaG,SagristaSauledaJ,SolerSolerJ.Primaryacutepericardialdisease:
Aprospectiveseriesof231consecutivepatients.AmJCardiol198556:623ZayasR,AnguitaM,
TorresF,etal.Incidenceofspecificetiologyandroleofmethodsforspecificetiologicdiagnosisof
primaryacutepericarditis.AmJCardiol199575:378ImazioM,CecchiE,DemichelisB,etal.
Indicatorsofpoorprognosisofacutepericarditis.Circulation2007115:2739.
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Indicationsforinvasiveworkupinacutepericarditis
Pericardiocentesis:
1.Cardiactamponade
2.Moderatetolargeeffusionsrefractorytomedicaltherapyandwithseveresymptoms
3.Suspectedbacterialorneoplasticpericarditis
Pericardialbiopsyandpericardioscopy(targetedbiopsyinspecialized
center):
1.Relapsingcardiactamponade
2.Suspectedbacterialorneoplasticpericarditis
3.Worseningpericarditis(despitemedicaltherapy)withoutaspecificdiagnosis
CourtesyofDr.MassimoImazio.
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Disclosures
Disclosures:MassimoImazio,MD,FESCNothingtodisclose.MartinMLeWinter,MDNothingto
disclose.BrianCDowney,MD,FACCNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,these
areaddressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsfor
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Clinical Presentation and Diagnostic Evaluation of Acute Pericarditis

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Clinical Presentation and Diagnostic Evaluation of Acute Pericarditis

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